The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.


Based on observation, document review and interview, it was determined that for 2 of 3 suspected patients for COVID-19 (corona virus/new strain of flu) (Pt. #1 and Pt. #3) in the intensive care unit (ICU), the Hospital failed to report to the local health department, to ensure compliance with the infection prevention and control program.

Findings include:

1. On 3/19/2020 at approximately 11:00 AM, an observational tour of the Hospital's ICU was conducted. During the the tour, it was identified that Pt. #1 and Pt. #3 were on droplet isolation precaution (preventive measures used for communicable disease). Pt. #1 and Pt. #3 were suspected cases for COVID-19.

2. On 3/19/2020 at approximately 3:00 PM, a document provided by the Hospital titled, "Clinical and Public Health Guidance for Managing COVID-19 Interim Guidance" (dated 3/18/2020) was reviewed and included, "... Reporting Persons With Suspected or Confirmed COVID-19 to Public Health: Local health departments and IDPH (Illinois Department of Public Health) receive positive test results directly from laboratories performing testing. However, providers should immediately report to the Local Health Department: 1) Persons who are part of a cluster of 2 or more possible or confirmed cases in a residential congregate settings that serve more vulnerable populations... 2) Any person hospitalized with pneumonia of unknown etiology who are from a residential congregate setting that serves more vulnerable populations such as assisted living facility, group home..."

3. On 3/19/2020 at approximately 3:10 PM, the Hospital's policy titled, "Reporting Communicable Diseases to the Chicago Department of Public Health" (revised 4/17) was reviewed and included, "... The Illinois Department of Public Health (IDPH) has determined certain diseases to be contagious, infectious, communicable, and in general, dangerous to the public health... Procedure...1. Class 1 (a) diseases require immediate notification by telephone within 3-hours of initial clinical suspicion and identification. Refer all calls to the Chicago Department of Public Health... The following diseases are considered to be Class I (a) reportable diseases: a) Any unusual case or cluster of cases that may indicate a public health hazard..."

4. On 3/19/2020 at approximately 1:30 PM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a female admitted on [DATE] with a diagnosis of pneumonia with unspecified organism (lung infection). The clinical record indicated that a COVID-19 testing was ordered on [DATE]. The clinical record also indicated that Pt. #1 had the same address as Pt. #3.

5. On 3/19/2020 at approximately 1:45 PM, the clinical record of Pt. #3 was reviewed. Pt. #3 was admitted on [DATE] with a diagnosis of pneumonia. The clinical record indicated that COVID-19 testing was ordered on [DATE]. The clinical record indicated that Pt. #1 had the same address as Pt. #3.

6. On 3/20/2020 at approximately 1:55 PM, the Hospital's Job Description for Infection Control Coordinator (undated) was reviewed and included, "... This position is responsible for the organization and implementation of surveillance, reporting... Essential Functions... D. Presents all suspected cases to infection control committee... II. Chicago Department of Public Health (CDPH) Cases... B. Report cases as needed to the CDPH..."

7. On 3/19/2020 at approximately 1:00 PM and on 3/20/2020 at approximately 11:00 AM, interviews were conducted with E #1 (Infection Control Preventionist). E #1 stated that she (E #1) is the one who reports to the local health department for suspected or confirmed reportable diseases. E #1 stated that she has not reported to the local health department that Pt. #1 and Pt. #3 are suspected cases for COVID-19. E #1 stated, "I called the son... the son told me that (Pt. #1) and (Pt. #3) live together..."

8. On 3/20/2020 at approximately 11:45 AM, an interview was conducted with MD #1 (Medical Director, Medical Stabilization Unit and Regulatory Compliance). MD #1 stated that COVID-19 is considered as an unusual case. MD #1 also stated that E #1 is the person who reports suspected or confirmed reportable diseases to the local health department, including COVID-19.

9. On 3/20/2020 at approximately 12:00 PM, an interview was conducted with MD #2 (Infectious Disease, Medical Chair). MD #2 stated that there was additional information, which was not shared with him (MD #2) regarding Pt. #1 and Pt. #3. MD #2 stated that Pt. #1 and Pt. #3 are part of a community church who had members identified as positive for COVID-19. If the previous statement is confirmed and based on the IDPH reporting guidelines, MD #2 stated that Pt. #1 and Pt. #3 falls under the category of reportable suspected cases to the local health department.